Chest Pain

1. Chest Pain In Children and Adolescents Caroline L. Derrick BSN, RN University of Michigan

2. Most causes are Benign • Common Complaint from Children in ER • Known association with myocardial infarction (MI) and sudden death in adults • In children, Cardiac causes are the least likely in association with presenting chest pain.

3. Studies • Nurse Practitioner Study: 50 Children with CP referred to Pediatric Cardiologist- non-cardiac cause. • 3/1,000 children visiting ER for CP, only 1% were cardiac in nature • LT outcomes in idiopathic CP- 81% reported no CP after 3 year follow up.

4. Differential Diagnosis • Musculoskeletal • Respiratory • GI • Idiopathic • Psychogenic • Cardiac

5. Musculoskeletal Pain • Muscle Strain:Chest wall pain- usually associated with strain of muscles and may occur with excessive exercise or trauma. • Strain of the upper back or pectoral muscles • Direct trauma to the chest- athletics, accidents, physical abuse. Trauma may include rib fractures, intercostal muscle strain, pneumothorax or hemothorax.

6. Costochondritis • 10-22% Childhood CP • Local, sharp pain in the mid-sternal area • Reproducible pain with palpation along costochondral margins • May last for several months • More common in girls • Treatment: Reassurance, NSAIDS, rest

7. Slipping Rib Syndrome • Sprain disorder r/t trauma to 8th, 9th, 10th ribs • Sensation of ribs “slipping” • Pain with flexing the trunk, turning over, deep breathing, prolonged walking, coughing • Positive “hooking maneuver” • Treatment: reassurance, injection of local anesthetic, possible surgical removal of affected cartilage.

8. Respiratory Causes • Pneumonia and Asthma may cause excessive coughing, may continue to overuse chest wall muscles. • Pleural Effusions- pain exaggerated by deep breathing • Pneumothorax- Chest pain • Tachypnea, retractions, wheezing, fever, decreased breath sounds. • CXR, SpO2%, peak flow meter levels

9. Gastrointestinal Pain • 2-7% of all causes of CP in adolescents • Esophagitis/GERD- “burning”, aggravated in a reclined position. • Pain with eating meals or spicy foods • Foreign body ingestion- toddlers; lodged in proximal esophagus • Caustic Ingestions- household cleaners- damage to esophagus • *** Bulimia Nervosa- purging- esophagitis/ perforation.

10. Idiopathic CP • Most common cause of childhood/adolescent CP • No organic or psychogenic cause after thorough history, PE, labs • Emotional stress/Anxiety, especially in girls • Hyperventilation Syndrome- hypercapnic alkalosis. Associated with lightheadedness, HA and parasthesias

11. Rare Causes of CP • Thoracic tumor • Sickle Cell Disease • Herpes Zoster • Ectopic Pregnancy • Precordial Catch- Texidor’s Twinge- Syndrome associated with CP. Described as brief (less than 5 minutes), sharp, shooting, left sided pain • Pain subsides with shallow breathing and straightened position • Thought to be produced by pressure on intercoastal nerve

12. Cardiac Causes of CP- Congenital Anomalies • Mitral Valve Prolapse(MVP) • Most prevalent cardiac lesion associated with CP in children/adolescence • Associated with thickening of mitral valve leaflets- bulge into the annulus. • Pain results from Left ventricular endocardial ischemia as the valve prolapses • 30% of MVP patients report CP • Mid-systolic ejection “click” • Systolic ejection murmur id regurgitation is present

13. Cardiac causes of CP- Congenital Anomalies • Left ventricular outflow obstruction- group of lesions that produce a significant risk for ischemic myocardial dysfunction. • Aortic Stenosis (AS) common- progressive over time- associated with bicuspid aortic valve • Causes a decrease in CO • CP with exertion • PE- systolic ejection click, systolic murmur over aortic valve region and palpable thrill at suprasternal notch • Aortic Stenosis Murmurs become louder when going from standing to squatting. • EKG- hypertrophy patterns may be present

14. Cardiac causes of CP- Congenital Anomalies • Subaortic Stenosis/ IHSS- obstructive lesions also associated with CP with exercise and exertion. • Harsh systolic murmor heard from squatting to standing. • IHSS inherited lesion- autosomal dominant pattern

15. Cardiac causes of CP- Congenital Anomalies • Anomalous Origin of the Left Coronary Artery- rare • Limited coronary artery blood flow, causing ischemia • Angina type pain, syncope • PE- Pan systolic continuous or mitral regurgitant murmur may be heard as well as a gallop.

16. Acquired Conditions • Pericarditis- infectious process causing inflammation of the pericardium • Sharp, shooting pain • Precordial in location • Often relieved by leaning forward • Cough fever, respiratory distress may be present • PE- heart sounds may be distant, muffled; a rub may be auscultated • Rub may disappear with development of pericardial effusion • EKG: ST segment or T wave change

17. Acquired Conditions • Kawasaki Disease- a history of this disease with coronary artery involvement, presenting with CP should be considered for myocardial ischemia. • Immunoglobulin treatment- without 20-25% children have coronary artery involvement at the time of presentation. • If administered within 10 days, incidence falls from 3-5% • Children with coronary artery abnormalities almost always have left ventricular hypertrophy • EKG: Abnormal ST segment or inverted T waves are noted in precordial leads.

18. Acquired Conditions • Cardiomyopathy- general term used to describe ventricular dysfunction • Many types- only some present with CP • Fatigue, decreased exercise tolerance, palpitations • Dilated Cardiomyopathy may have CP with exertion and a systolic murmur. • Ask about a familial history of sudden cardiac death when a child has dilated cardiomyopathy.

19. Acquired Conditions • Myocarditis preceded by viral illness • Children may have a fever, malaise, nonspecific CP, respiratory distress. • PE- may produce evidence of a gallop • Chest radiograph- cardiomegaly • ECG- ST segment depression and T wave abnormalities

20. Arrhythmias • SVT (Supraventricular tachycardia)- may cause CP. Most common childhood arrhythmia • Rapid heartbeat>200 bpm • PE: diaphoresis, pallor, hypotension, syncope • Can convert to SR with vagal Stimulation • Frequent episodes of syncope, treatment options include: pharmacologic therapy (Adenosine) or ablation

21. Arrhythmias • Ventricular Tachycardia (VT)- rare but associated with CP • Wide complex tachycardia • Rate 120-140 bpm • Medical Emergency- may progress to Ventricular fibrillation • Causes: viral myocarditis, surgically induced sequelae or prolonged QT interval.

22. Questions to Ask:Past Medical History • History of: asthma, sickle cell disease, rhematic fever, cystic fibrosis?- CP may indicate a complication. • History of congenital or acquired heart disease? Even if it was fixed may produce CP.

23. Severity of CP • Scale “0-10” or smiley faces • Worst pain ever? • Interfere with daily activities? • What makes the pain better? Worse? • Any associated factors related to the chest pain? • Organic vs. Psychogenic pain

24. Onset, Frequency, Duration • When did the pain start? • What were you doing when the pain started? • How often does the pain occur? • When does the pain occur? What activities are you doing? • How long does the pain last, is it continuous or does it come and go (intermittent)? • How long has this been going on?

25. Type and Location • How would you describe the pain? Sharp, dull, burning, pressure, etc? • Sharp pain- costochondritis, musculoskeletal, may be located along costochondrial junction • Burning- espohagitis, indigestion, may be located at midsternal area. • Where is the pain located, does the pain radiate (travel) to any other areas? (jaw, neck, shoulders, abdomen, arm, etc.) • Sharp pain that radiates to the neck, back and shoulders may be associated with pneumomediastinum

26. Associated Symptoms • Palpitations • Dizziness • Syncope with CP • *** These symptoms are associated with cardiac causes of CP and should be taken seriously • Recent Flu like symptoms, prolonged fever with new onset of CP- endo, pericarditis, myocarditis- immediate work-up required

27. Precipitating Factors • Anxiety- explore recent events- new school?, etc. • Tend to complain of CP during the week but not on weekends, holiday breaks or summer.

28. Family Events • Ill family member? Divorce? Physical or sexual abuse? • Girls: BCP- rare Pulmonary embolism • Depression- stressors

29. Family History • Pivotal • History of acquired or congenital heart disease, Marfan Syndrome or history of arrhythmia • Critical- history of sudden cardiac death in a family member • Idiopathic hypertrophic subaortic stenosis- autosomal dominant disorder associated with sudden cardiac death.

30. Physical Exam • Complete • Signs of severe distress, pain, anxiety • Vital signs,BP and weight within range for age? • Assess respiratory function for distress or abnormalities • Ecchymosis, trauma, rash, chest heave, abnormal shape of chest, scoliosis or syndromic appearance. • Tall and thin with long fingers and toes? (Marfan Syndrome)

31. Physical Exam • Palpate chest wall to attempt to reproduce or locate source of CP • Include clavicals, entire chest wall, breasts and zyphoid area • Assess for palpable thrill or RV heave- both consistent with congenital and acquired heart disease • Subcutaneous emphysema- trauma or spontaneous pheumothorax? • Palpate abdomen- tenderness and assess for hepatosplenomegaly

32. Physical Exam • Palpate extremities for warmth and general perfusion • Assess pulses in all four extremities for equality and strength • Hooking maneuver • Auscultate the heart for murmurs, gallops, rubs, dysrhythmias and any other abnormal heart sounds • Auscultate in supine, sitting , standing and squatting positions- helps to hear murmurs of AS and sub AS. • Lie patient on left side- assess for murmur of mitral regurgitation or mitral valve click • Auscultate all lung fields assess for wheezes, rales, or asymmetry of breath sounds

33. Further Evaluation • Labs usually not needed • In most cases, H& P will clarify cause • Consider peak flow meter if asthma may be the cause • Order CXR if signs of pleural effusion, pneumothorax, pneumonia, chest trauma, or bone fracture • Consider pregnancy test • 12 lead ECG • Holter Monitors, journal/diary • Journal/diary of events surrounding CP • Exercise Stress Testing- cardiac rhythm during exercise • Referral if cardiac in origin

34. Good Prognosis • CP in children/adolescents common and rarely cardiac related • Thorough H & P essential to rule out rare and life threatening causes of CP • Most causes of CP are benign and cause no further sequelae.